Meningitis Caused by Cryptococcus Gattii in a Person Living With Hiv: A Case Report of Refractory Intracranial Hypertension and Limited Access to Neurosurgical Management in the Brazilian Public Health System

Cryptococcal meningoencephalitis due to Cryptococcus gattii is classically associated with immunocompetent individuals; however, its epidemiology in Brazil and clinical course in people living with HIV require further investigation. A 28-year-old cisgender woman, diagnosed with HIV two years earlier and not previously on antiretroviral therapy, was admitted with severe holocranial headache for seven days, diplopia, vomiting, and fever. Physical examination showed neck stiffness, positive Kernig sign, and bilateral sixth cranial nerve palsy. Admission head CT was unremarkable. Laboratory tests showed a reactive serum cryptococcal antigen (LF-CrAg), HIV viral load of 68,300 copies/mL, and CD4 count of 72 cells/mm³. Lumbar puncture revealed an opening pressure of 38 cmH₂O and CSF analysis with 510 cells (97% mononuclear), protein 52 mg/dL, normal glucose, reactive LF-CrAg, and culture growth of C. gattii. Workup for other opportunistic infections was negative. She developed refractory intracranial hypertension, requiring 26 therapeutic lumbar punctures during the initial hospitalization. Induction therapy with liposomal amphotericin B plus flucytosine lasted four weeks, followed by fluconazole consolidation. Although early CSF diversion was indicated, it was not performed due to structural limitations in the health system. The patient stabilized transiently, started antiretroviral therapy, and was discharged. Ten days later, she was readmitted with recurrent intracranial hypertension, requiring nine additional therapeutic lumbar punctures until pressure stabilization, without mycological evidence of relapse, totaling 35 procedures since diagnosis. At one-year outpatient follow-up, she remains on fluconazole maintenance without complications or relapse. Notably, there was clinical–radiological dissociation, as follow-up CT scans did not show signs of intracranial hypertension, consistent with the “frozen brain state” described in the literature, attributed to deposition of C. gattii capsular polysaccharide. Guidelines recommend CSF diversion if intracranial hypertension persists for more than seven days despite therapeutic lumbar punctures, contrasting with the more than 60-day persistence in this case. Intracranial hypertension management in cryptococcal meningitis is directly associated with reduced mortality, and pharmacologic treatment offers no benefit. This case highlights the limitations of exclusive clinical management and reinforces the importance of early neurosurgical intervention.